Soap Note: Acute Myocardial Infarction

Follow the Soap Note Rubric as a guide:

Use APA format and must include minimum of 2 Scholarly Citations.

Soap Note Rubric:

  

(Student Name)

Miami Regional University

Date of Encounter:

Preceptor/Clinical Site:

Clinical Instructor: 

Soap Note # 1     Main Diagnosis: Acute Myocardial Infarction

PATIENT INFORMATION

Name:

Age: 

Gender at Birth: 

Gender Identity: 

Source: 

Allergies: 

Current Medications: 

 

PMH: 

Immunizations: 

Preventive Care: 

Surgical History: 

Family History:

Social History: 

Sexual Orientation: 

Nutrition History: 

Subjective Data:

Chief Complaint: 

Symptom analysis/HPI:

The patient is … 

Review of Systems (ROS)

CONSTITUTIONAL: 

NEUROLOGIC: 

HEENT: 

RESPIRATORY: 

CARDIOVASCULAR: 

GASTROINTESTINAL: 

GENITOURINARY: 

MUSCULOSKELETAL: 

SKIN: 

Objective Data:

VITAL SIGNS: 

GENERAL APPEARANCE: 

NEUROLOGIC:

HEENT: 

CARDIOVASCULAR: 

RESPIRATORY: 

GASTROINTESTINAL: 

MUSKULOSKELETAL:

INTEGUMENTARY: 

ASSESSMENT:

Main Diagnosis

(Include the name of your Main Diagnosis along with its ICD10 I10. (Look at PDF example provided) Include the in-text reference/s as per APA style 6th or 7th Edition. 

Differential diagnosis (minimum 3)

-

-

-

PLAN:

Labs and Diagnostic Test to be ordered (if applicable)

· - 

· - 

Pharmacological treatment: 

-

Non-Pharmacologic treatment: 

Education (provide the most relevant ones tailored to your patient)

Follow-ups/Referrals

References (in APA Style)

Examples 

Codina Leik, M. T. (2014). Family Nurse Practitioner Certification Intensive Review (2nd ed.). 

ISBN 978-0-8261-3424-0

Domino, F., Baldor, R., Golding, J., Stephens, M. (2010). The 5-Minute Clinical Consult 2010

(25th ed.). Print (The 5-Minute Consult Series).

I attached one example:

Please no plagiarism!!!